• Max Zworth, Hashim Kareemi, Suzanne Boroumand, Lindsey Sikora, Ian Stiell, and Krishan Yadav.
• Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. mzworth@toh.ca.
• CJEM. 2023 Oct 1; 25 (10): 818827818-827.

ObjectivesPrompt diagnosis of acute coronary syndrome (ACS) using a 12-lead electrocardiogram (ECG) is a critical task for emergency physicians. While computerized algorithms for ECG interpretation are limited in their accuracy, machine learning (ML) models have shown promise in several areas of clinical medicine. We performed a systematic review to compare the performance of ML-based ECG analysis to clinician or non-ML computerized ECG interpretation in the diagnosis of ACS for emergency department (ED) or prehospital patients.MethodsWe searched Medline, Embase, Cochrane Central, and CINAHL databases from inception to May 18, 2022. We included studies that compared ML algorithms to either clinicians or non-ML based software in their ability to diagnose ACS using only a 12-lead ECG, in adult patients experiencing chest pain or symptoms concerning for ACS in the ED or prehospital setting. We used QUADAS-2 for risk of bias assessment. Prospero registration CRD42021264765.ResultsOur search yielded 1062 abstracts. 10 studies met inclusion criteria. Five model types were tested, including neural networks, random forest, and gradient boosting. In five studies with complete performance data, ML models were more sensitive but less specific (sensitivity range 0.59-0.98, specificity range 0.44-0.95) than clinicians (sensitivity range 0.22-0.93, specificity range 0.63-0.98) in diagnosing ACS. In four studies that reported it, ML models had better discrimination (area under ROC curve range 0.79-0.98) than clinicians (area under ROC curve 0.67-0.78). Heterogeneity in both methodology and reporting methods precluded a meta-analysis. Several studies had high risk of bias due to patient selection, lack of external validation, and unreliable reference standards for ACS diagnosis.ConclusionsML models have overall higher discrimination and sensitivity but lower specificity than clinicians and non-ML software in ECG interpretation for the diagnosis of ACS. ML-based ECG interpretation could potentially serve a role as a "safety net", alerting emergency care providers to a missed acute MI when it has not been diagnosed. More rigorous primary research is needed to definitively demonstrate the ability of ML to outperform clinicians at ECG interpretation.© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).

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